What's the birth control ring?

The birth control ring (the NuvaRing) is a type of hormonal contraception. It's a soft, flexible transparent ring that measures about 2 inches in diameter and is less than a quarter of an inch thick. (The ring does not contain latex.)

You insert the ring into your vagina at the beginning of your cycle and leave it there for three weeks. Once inside, the ring releases a continuous low dose of synthetic estrogen and progesterone (progestin). These are the same two hormones you'd get from taking the combination pill (the Pill).

After three weeks, you take the ring out and leave it out for exactly one week, during which time you'll get your period. When you've completed the 28-day cycle (21 consecutive days with the ring in, followed by seven days without it), you insert a new ring the next day.

How does the birth control ring prevent pregnancy?

The ring continuously releases low levels of estrogen and progestin, which enter into your system when they're absorbed through the vaginal walls. Just as they do in combination pills, these hormones keep your ovaries from releasing eggs.

The progestin has other contraceptive effects, as well. It thickens your cervical mucus, making it more difficult for sperm to get into your uterus and fallopian tubes where one might fertilize an egg, if an egg were released. The changes in your mucus may also inhibit the process a sperm must undergo to be able to penetrate the tough outer coating of an egg.

Finally, progestin thins the lining of your uterus, theoretically making it less likely that an egg could implant there if it did get fertilized.

Can I use the ring if I'm breastfeeding?

If breastfeeding is going well after six weeks postpartum, it's okay for you to use the ring. If you're not producing as much milk as you'd like, or if your baby is having any trouble nursing, though, the ring may not be a good choice for you, because it may reduce the amount of milk you produce by a bit.

How effective is the ring?

When used correctly and consistently, the ring is about 99 percent effective. This means that only one woman out of 100 who use the ring properly will get pregnant in the first year.

If you don't use the ring exactly as prescribed — for example, you don't keep it in continuously for three weeks or you wait too long to put in a new ring without using backup contraception — the likelihood that you'll get pregnant is much higher.

Although the ring is an excellent contraceptive method, it doesn't offer any protection against sexually transmitted infections (STIs). So if you're at risk for STIs, you'll need to use condoms as well.

What will I need to do if I decide I want to get pregnant?

All you have to do to reverse the effects of the ring is to stop using it. You don't have to keep it in for the rest of your cycle unless you want to. In any case, you'll most likely get your period within a few days after you take out the ring. For most women, fertility returns soon after they stop using the ring, typically within two to four weeks.

Some practitioners recommend using a barrier method of contraception (such as condoms or a diaphragm) after discontinuing the ring and waiting until you have a couple of normal periods before trying to conceive. This can help you establish a more accurate due date. Others will give you the go-ahead to start trying right away if you want to.

If you do get pregnant before your periods become regular again, don't worry — you can have an early sonogram to date your pregnancy.

By the way, you'll want to make sure you've been taking 400 milligrams of folic acid a day for at least one month before you start trying to conceive. (In fact, health experts recommend that all women of childbearing age take folic acid every day, either alone or in a multivitamin.)

It's also a good idea to see your healthcare provider for a preconception checkup a few months before you start trying.

How can I get the birth control ring?

You'll need to see your caregiver for an exam. If you're an appropriate candidate for the ring — that is, you have no health risks and feel comfortable inserting the ring in your vagina — your health practitioner will write you a prescription. There's no fitting necessary: One size fits all.

Thanks to the Affordable Care Act, insurance plans must cover all prescription contraceptive methods completely – with no cost to you. Plans that existed on March 23, 2010 – and some religiously affiliated employers – are exempt, but many are complying with the changes anyway.

If you're paying out of pocket, you can expect to spend between $15 and $80 a month, plus the cost of the exam. The ring may be available at some family planning clinics for less.

When can I start using the ring and will I need to use a backup method at first?

You can start using the ring six weeks after you give birth. That's because new moms have a particularly high risk for blood clots during the early postpartum weeks, and the estrogen in the ring increases this risk even more.

Because new mothers who aren't breastfeeding exclusively may ovulate within a month after delivery, you'll need to abstain from sex or use another method of contraception during this time, such as the progestin-only mini-pill or condoms.

You'll want to make sure that you're not already pregnant when you start using the ring. One way to know for sure is to start using the ring when you get your period, which usually resumes within eight weeks after delivery if you're not nursing.

You don't have to wait for your period if you've been abstinent or consistently using another form of contraception since you gave birth. However, you will need to abstain or use backup contraception (such as condoms) for the first seven days on the ring.

Don't use a diaphragm or a cervical cap as your backup method because a ring can interfere with the correct placement and position of these barrier contraceptives.

If you're already menstruating again, you can be sure you're not pregnant if you insert the first ring within five days after your period starts. If you're starting the ring for the first time and insert it on the first day of your cycle — that is, the day you get your period — you'll be protected immediately and won't need to use any backup contraception.

However, if you insert the ring sometime during the second through fifth day of your cycle, you'll need to abstain or use condoms for the first seven days of that cycle to ensure you don't get pregnant.

If you're sure you're not pregnant — that is, you haven't been sexually active since your last period or you've been consistently using another reliable method of birth control — your caregiver may give you the go-ahead to insert the ring regardless of where you are in your menstrual cycle. With this method, you'll need to abstain or use condoms for at least the first seven days because the ring won't be effective immediately.

If you're switching to the ring from the combination birth control pill or patch, you can switch at any time. If it's the end of a Pill or patch cycle, be sure to insert the NuvaRing no later than the day you would have started a new pill pack or a new patch. If you've been using these methods exactly as prescribed without missing a pill or patch and you insert the ring on time, no backup method is needed.

If you've been using the minipill, you can switch on any day, but you must use a backup method such as condoms for seven days after you insert the first ring.

How exactly do I use the birth control ring?

Preparing to use the ring

First, read the instructions that come with the ring. If you don't have them on hand, you can find them on the NuvaRing website. Also, make sure you always have an extra ring at home so you won't have a problem if your pharmacy is closed when you need to insert a new one.

Store the unopened package away from high heat and direct sunlight. Temperatures above 86 degrees Fahrenheit and direct sunlight can render the ring ineffective. (If your home tends to get hot, store the package in the refrigerator, but don't put it in the freezer.)

You'll also need to keep condoms around to use for backup contraception, which you may need when you insert the first ring and will definitely need if you insert a new ring late. You should also be using condoms if you're at risk for sexually transmitted infections.

Before inserting a new ring, double-check the expiration date on the package. Then wash your hands with soap and water. Press the sides of the ring together between your thumb and index finger, then gently push the ring all the way into your vagina where it will unfold on its own when you let go.

If you can feel the ring in your vagina, use your finger to gently push it in further. The ring will be equally effective no matter where it is in your vagina.

Once a ring is in place, leave it there for three straight weeks. If for any reason the ring is out of your vagina for more than 3 hours at a time during these three weeks, you are not protected and will need to use backup contraception such as condoms for the next seven days after the ring is reinserted.

Removing the ring

After you've had the ring in for 21 days in a row, remove it and begin a seven-day ring-free break. During this week, you'll likely get your period (possibly just scant bleeding), which will typically start two to three days after you take the ring out. You'll still be protected against pregnancy during this hormone-free week and don't need to use a backup method.

To remove the ring, insert your index finger into your vagina, hook it under the ring and pull it out. Dispose of the ring by putting it in the pouch it came in or in a sealed bag before throwing it in the garbage. (Make sure children or pets can't get to it.) Do not flush the ring down the toilet.

Starting the next ring

It's very important to insert a new ring no more than one week after you removed the last one. If the ring-free interval lasts more than seven days, you'll no longer be protected against pregnancy.

Insert the new ring at this time even if you still have some menstrual bleeding. As long as you insert the new ring on time, you'll have continuous protection and won't need to use backup contraception.

If more than seven days have passed since you removed your ring and you haven't yet inserted a new one, you'll need to use another method of contraception if you have sex. Once you do insert a new ring, you'll need to use a backup method of contraception (like condoms) for the first seven days after the ring is inserted.

It's a good idea to mark on your calendar when you put the ring in, when it should come out, and when you're due to insert a new ring.

Protecting yourself from STIs

The ring won't protect you against HIV, gonorrhea, chlamydia, or any other sexually transmitted infections. So if you or your partner is having sex with anyone else or using illicit IV drugs, you'll need to make sure your partner uses a latex condom (or a polyurethane one if either of you is allergic to latex) every time you have sex.

What if the ring slips out of my vagina?

Although it doesn't happen often, a ring can slip out of your vagina while you're removing a tampon or straining during a bowel movement. (After removing a tampon or straining, check to make sure you haven't expelled the ring.)

A ring may be more likely to slip out if you have a condition affecting the structure of the vagina, such as a prolapsed uterus or very relaxed vaginal muscle tone.

If the ring comes out of your vagina, rinse it with cool to lukewarm (not hot) water and reinsert it as soon as possible. You'll continue to be protected against pregnancy if you put it back in place within three hours.

If the ring has been out of your vagina for more than three continuous hours during the first or second week of use, you should still rinse it off and reinsert it, but you'll need to use a backup method of birth control for the next seven days.

If the ring is out of your vagina for more than three continuous hours during the third week of use, discard it. At this point you can insert a new ring right away and start a new 28-day cycle or wait seven days so you can have your period before you insert a new ring. If you choose to wait a week, you'll need to use backup contraception until the new ring has been in place for at least seven days.

If you lose a ring when it comes out, just insert a new one and start a new cycle. (If a new one is not inserted within three hours, make sure to use backup contraception for the next seven days.) If the rings come out repeatedly, call your healthcare provider. You might need to switch to another method of birth control.

If the ring has been out for more than three hours and you've had unprotected intercourse during this time, consider using emergency contraception to decrease your odds of becoming pregnant.

What if I forget to take the ring out on schedule?

If you forget to take the ring out after three weeks, but it's been in for no longer than 28 days, you're still protected against pregnancy. In this case, take the ring out and insert a new one after seven days.

However, if the ring has been in for more than four weeks, you're no longer protected against pregnancy.

If you haven't have sex or you used a backup method during this time, you can insert a new ring right way. When you do insert the new ring, you'll need to continue to abstain or use backup contraception for the next seven days.

If you had sex without backup contraception after the ring has been in for four weeks, consider using emergency contraception immediately. You'll need to make sure that you're not pregnant before you insert a new ring. Use backup contraception until the new ring has been in for seven days.

What should I do if I don't get my period during the last week of my cycle?

You'll usually get your period two or three days after removing the ring. Women using the ring often have shorter, lighter periods. Some have no more than one day of scant bleeding.

Some women using the ring occasionally skip their period altogether for a cycle. If this happens to you and you've been using the ring exactly as prescribed, don't panic — just insert a new ring on schedule. It's highly unlikely that you're pregnant, but if you're worried you can take a home pregnancy test for reassurance.

However, if you miss two periods in a row or if you miss a single period when you haven't used the ring correctly and consistently, call your caregiver so she can make sure you're not pregnant before you insert your next ring. Use another method of birth control in the meantime.

There's no need to panic if you inserted a ring before suspecting that you might be pregnant. There's no evidence that hormonal contraception used inadvertently in early pregnancy can harm a developing baby.

Is it a good idea to take a break from the ring occasionally?

No. As long as you don't develop a problem that requires you to stop using the ring, there's no medical reason to stop or take a break. And unless you switch to another reliable contraceptive method, you risk becoming pregnant. (You may need to start your new method up to a week before you stop using the ring.) Plus, when you return to using the ring, you may wind up having annoying side effects again for the first few cycles.

Are there any medications that make the ring ineffective?

Some medications and herbal preparations can affect the way hormonal contraceptives work. And hormonal contraceptives can make some other drugs more or less potent. Be sure to tell any healthcare provider you're seeing that you're using the ring.

Also tell the practitioner prescribing the ring about every other medication you take, including herbal supplements. Substances that are known or strongly suspected to reduce the effectiveness of hormonal contraceptives include the herb St. John's Wort (Hypericum perforatum), the antibiotic rifampin, barbiturates, some HIV drugs, a number of antiseizure medications, and an antifungal drug called griseofulvin.

Most medications, including routine antibiotics (such as those you might take for a urinary tract infection, for example. And vaginal antifungal medications for yeast infections won't reduce the effectiveness of the ring.

If you need to take a medication that interferes with the contraceptive action of the ring and you'll be taking it for a long time, talk to your practitioner about other contraceptive methods. If you'll only be taking the medication for a short time, you can continue on the ring but you'll need to use backup contraception at the same time and for seven days after the drug is cleared from your body.

Because some medications take longer to leave your body, you may need to use a backup method for more than seven days after you stop taking the drug. Ask your caregiver for specific guidance about any prescription you're given.

What side effects does the ring have?

The dose of estrogen you get from the ring is lower than the dose in the Pill, so you're less likely to have side effects from it. In general, if you experience side effects, they're most likely to occur during the first two or three months of use. Some women may have:

Small changes in weight

Breast tenderness or enlargement

Nausea or, more rarely, vomiting

Mood changes

Headaches

Difficulty wearing contact lenses

You may also have spotting or bleeding between periods, which is known as breakthrough bleeding. This occurs in only a minority of women using the ring and often goes away after a few cycles.

A small percentage of women complain of vaginal irritation when using the ring, and some ring users report more vaginal wetness.

Finally, some women using combined hormonal contraception develop chloasma, or areas of darkened skin, usually on the face, although this is less likely to occur with low doses of estrogen. Skin darkening is more likely to be an issue for you if you had chloasma during pregnancy.

You can lower your chances of getting chloasma now by protecting your skin from the sun with sunscreen and clothing. If you do develop chloasma, there's no risk to your health, but you'll want to switch to another method of contraception that doesn't contain estrogen. The skin darkening may worsen if you continuing using the ring.

What symptoms may indicate a medical problem from the ring?

Call your health practitioner immediately if you notice any of these symptoms:

Sharp pain in the chest

Shortness of breath

Coughing up blood

Severe abdominal pain, tenderness, or swelling

Swelling in one leg, or severe calf or thigh pain

Migraine headaches, severe headaches of any kind, or headaches that are more intense than they were before you started the ring

Any neurological symptoms, including visual disturbances (such as blurred or double vision, temporary loss of vision, flashing lights or spots before your eyes), slurred speech, and tingling or weakness on one side of the body

A sudden high fever accompanied by vomiting, diarrhea, dizziness, weakness, sore throat, achiness, redness of the eyes, or a sunburn-like rash. These are signs of toxic shock syndrome, a rare but serious condition that's associated with tampon use and certain barrier contraceptives, like the diaphragm. (Very few cases have been reported in ring users, some of whom were also using tampons, so cause and effect is not known.)

Call without delay if you develop a severe skin rash, become jaundiced (yellowing of your skin or eyes), feel itchy all over, notice a lump in your breast, feel depressed, or have severe mood swings. And, of course, contact your caregiver if you think you might be pregnant